CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATIONUse and Disclose Your Health Information • May 24th, 2021
This form is an agreement between you, and the Family Guidance Center of Warren County. The word ''you" means you, your child, relative, or other person for whom you are a personal representative.
This form is an agreement between you, and meUse and Disclose Your Health Information • September 9th, 2021
Katherine Ziff, LPC, Ph.D., and supervising psychologist, Kristina Houser, Ph.D., Licensed Psychologist, LPCC-S When I use the word “you”, it will mean your child, relative, or other person if you have written his or her name here:
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATIONUse and Disclose Your Health Information • September 25th, 2019
This form is an agreement between you, and Matthew J. Mauriello, MA, P.C. (DBA “The Mauriello Group”). When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name below as the identified client.
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATIONUse and Disclose Your Health Information • March 12th, 2015
This form is an agreement between you, , and Kristina Kops, Psy.D. When I use the word “you” below, it will mean your child, relative, or other person if you have written his or her name here: .
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATIONUse and Disclose Your Health Information • March 12th, 2015
This form is an agreement between you, , and Kristina Kops, Psy.D. When I use the word “you” below, it will mean your child, relative, or other person if you have written his or her name here: .
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATIONUse and Disclose Your Health Information • November 7th, 2020
Information collected here as part of your evaluation, treatment and/or referral is legally called Protected Health Information (PHI) about you. This information is used here to determine what treatment is best for you and to provide treatment to you. This information may also be shared with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.
